Collinsville, Oklahoma
February 9, 2012
HIV/STD Opt-Out
State Mandated Prevention Information
Opt Out Requires Written Request

Before March 27th, 2012, send to this address: School Health Office, c/o Mr. Terry Due, Superintendent of Schools, 12818 N 129th E Ave, Collinsville, OK. 74021. This request must be made in writing in order to satisfy the requirements of the State of Oklahoma.
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Parent Permission to Excuse Student from HIV/STD Education

My child will be excused from HIV/STD education for 2012 school year.

Student Name: __________________________

Parent Name (Printed): ________________________

Parent Signature: ________________________

Date: ______________________